This presentation is a part of the PEER Liberia Behavioral Health Lecture Series. It provides an overview of trauma-informed peripartum care, including recognizing the signs, screening and management of peripartum and postpartum trauma

Dykhouse, Elizabeth C.

Gwaltney, Rebecca

English

eScholarship@UMMS

University of Massachusetts Medical School eScholarship@UMMS PEER Liberia Project UMass Medical School Collaborations in Liberia 2021-04-08 Trauma-Informed Peripartum Care Rebecca Gwaltney University of Massachusetts Medical School Et al. Let us know how access to this document benefits you. Follow this and additional works at: https://escholarship.umassmed.edu/liberia_peer  Part of the Family Medicine Commons, Maternal and Child Health Commons, Medical Education Commons, Mental and Social Health Commons, Obstetrics and Gynecology Commons, Psychiatry and Psychology Commons, Trauma Commons, and the Women's Health Commons Repository Citation Gwaltney R, Dykhouse EC. (2021). Trauma-Informed Peripartum Care. PEER Liberia Project. https://doi.org/10.13028/1t40-de17. Retrieved from https://escholarship.umassmed.edu/liberia_peer/79 This material is brought to you by eScholarship@UMMS. It has been accepted for inclusion in PEER Liberia Project by an authorized administrator of eScholarship@UMMS. For more information, please contact Lisa.Palmer@umassmed.edu. TRAUMA-INFORMED PERIPARTUM CARERebecca Gwaltney, MD and Elizabeth Dykhouse, PhDDEPARTMENT OF FAMILY MEDICINE & COMMUNITY HEALTH, UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOLContent adapted with permission from presentation by Jordan Howard-Young, MD8 April 2021ROADMAP1 RECOGNIZING THE SIGNSsigns and symptoms; Epidemiology2 ANTENATAL CAREScreening, and management3 PERIPARTUM CAREAvoiding exacerbations and preventing birth trauma4 POSTPARTUM CAREProcessing trauma and breastfeeding considerationsWhat does trauma look like from the outside?Being aware of signs and symptoms► Anxious► Tense► Avoidant► Zoned out► Sounding scripted when recounting trauma► Jumpy► Reckless► Depressed► Irritable► Angry► Suspicious► Guarded► Distrustful of authority► Hypersexual► Ashamed► Trouble sleeping► Pain intolerant► Somatic symptoms► Self-harm► Substance use► Difficult cervical exams► Distress with male providersWHAT DOES TRAUMA LOOK LIKE FROM THE OUTSIDE?EPIDEMIOLOGY OF TRAUMAEpidemiology, screening, and managementEPIDEMIOLOGY80%8%30%Percentage of women who have experienced trauma in their lifetimeLifetime prevalence of PTSD among women in the USPrevalence of postpartum PTSD among all postpartum womenPercentage of women who experience subclinical postpartum symptoms4%EPIDEMIOLOGYIn West Africa“ Most western studies of war-related post-traumatic stress disorders (PTSD) have been in exiled refugees or combat veterans with only a few addressing the plight of those who stayed behind in their communities . Mollica has described considerable psychiatric disability in those massively traumatised communities who stayed behind in their countries of war - trauma, as was on the Thailand – Cambodia border and in the former Yugoslav republics. In Africa, in a study of treated war traumatised survivors, Musisi, described significant psychiatric disability in survivors of war living within their own country . In all these studies, the most common disorders were PTSD, depression, anxiety, and problems in coping with life from day to day. Various workers have described the psychiatric evaluation and treatment of massively traumatised individuals such as war-refugees or earthquake victims. Such studies are rare in Africa. “Mass trauma and mental health in Africa Seggane Musisi - Department of of Psychiatry, Makerere University Medical School & Mulago Hospital - Afr Health Sci. 2004 Aug; 4(2): 80–82. “Some workers have cautioned against the “medicalisation” of what they see as normative human response to extreme adversity as happens in war. However, most studies of mass trauma point to a core set of mental health symptoms in traumatised individuals but which symptoms may lend themselves to varied expressions in different cultural settings. These symptoms centre on the concept of the diagnostic categories of PTSD, depression and anxiety disorders including panic anxiety and phobias.”Both impact on the mental and public health African Health Sciences Vol 4 No 2 August 2004 81 of communities and the eventual socio-economic development of societies as well as to the mass psycho-social behaviour of communities e.g. increases in domestic violence, child abuse, substance abuse or the tendency to use militarism resolve all forms of conflict even at interpersonal level.However, for the presently traumatised populations, efforts at decentralised mental health care through an integrated Primary Health Care approach is deemed most practical, appropriate, affordable and achievable. This calls for appropriate training of primary mental health counsellors, and all health care providers in the awareness, recognition and management of problems of mass trauma and their associations. These treatment approaches would involve culturally, gender and age sensitive psychotherapeutic approaches, social support and affordable medications where indicated.It behoves all African scholars, and health workers in particular, to research and publicise the causes, effects and sequels of mass trauma on our peoples and to find appropriate solutions both for prevention and treatment.Recent evidence points to demonstrable neurobiological changes in the brains of individuals with PTSD such as hippocampal atrophy, amygdaloidal hypersensitivity or Hypothalamic – Pituitary – Adrenal Axis dysfunction thus giving neuro-biological correlation to the effects of psycho-traumatisation. Co morbidity is common and often, there are other associated psychological problems such as substance abuse, personality changes and general psychosocial dysfunction in the life after trauma of affected individuals.POSTTRAUMATIC STRESS DISORDERDIAGNOSTIC CRITERIA IN DSM 5Exposed to actual or threatened death, actual or threatened serious injury, or actual or threatened sexual violence by:1. Personal experience2. Witnessed in person3. Learned of a relative or close friend’s trauma4. Detailed or repeated indirect exposure, usually in the context of professional responsibilitiesCriterion A: TraumaAPOSTTRAUMATIC STRESS DISORDERDIAGNOSTIC CRITERIA IN DSM 5Recurrent, involuntary, and intrusive recollections; traumatic nightmares; dissociations (e.g., flashbacks); intense or prolonged distress to triggers; marked physiological reactivity to stimuliCriterion B: Intrusion (1/5)B Negative alterations that began or worsened after trauma: inability to recall key details; negative beliefs about self; blame of self or others; negative emotions; anhedonia; alienation; constricted affectCriterion D: Cognition, Mood (2/7) DPersistent effortful avoidance of: trauma-related thoughts or feelings; external reminders (e.g., people, places, conversations, activities, objects, or situations)Criterion C: Avoidance (1/2)C Alterations that began or worsened after trauma: irritable or aggressive; self-destructive or reckless behavior; hypervigilant; easy to startle; trouble concentrating; sleep disturbancesCriterion E: Arousal, Reactivity (2/6)EPOSTTRAUMATIC STRESS DISORDERDIAGNOSTIC CRITERIA IN DSM 5Symptoms last for more than one monthCriterion F: DurationF Symptoms create distress or functional impairment (e.g., social, occupational)Criterion G: FunctionGSymptoms are not better explained by medication, substance use, or another medical conditionCriterion H: ExclusionHOTHER RELEVANT DISORDERSVery similar criteria to PTSD,     but duration is between           three days and one monthAcute Stress DisorderEmotional or behavioral symptoms in response to an identifiable stressor within three months of its onset. 1. Depressed mood2. Anxiety3. Mixed anxiety and depressed mood4. Disturbance of conduct5. Mixed disturbance of emotions and conduct6. UnspecifiedAdjustment DisordersANTENATAL CARE ManagementFETAL IMPACT OF MATERNAL STRESS MATERNAL STRESS OR DEPRESSIONHPA AXIS DYSREGULATION ⇧ CRH LEVELSSTIMULATES ONSET OF   LABOR, PTL⇧ CORTISOL LEVELS⇩ PLACENTAL BLOOD FLOW, LBWPROGRAMMING OF FETAL          HPA AXISDYSREGULATION OF FETAL          HPA AXIS⇧ REACTIVITY      TO STRESS⇧ VULNERABILITY TO MOOD AND ANXIETY D/O’S► Screen for PTSD in pregnant patients► Treat when indicated► Discuss the delivery experience with every patient► Anticipate and document potential challenges► Encourage birth plans that empower women and promote a sense of safety► Pain management► Environmental controls (music, lighting, mirrors, etc.)► Interpersonal support► Agency over physical exams► Helpful coaching (volume, number of coaches, tone, etc.)TRAUMA-INFORMED ANTENATAL CAREWhat can we do as providers?PTSD MANAGEMENT IN PREGNANCY• Cognitive Behavioral Therapy (CBT)• Eye Movement Desensitization and Reprocessing (EMDR)Psychotherapy• Well established safety profiles (conflicting evidence on paroxetine)• Best choice is whatever has worked in the past• Limited evidence, but benefits will often outweigh the risks• Highest concern is for hypotension, so low starting dose (1 mg)Prazosin• SNRIs may increase risk of HTN, PPH, ?PTL• Mirtazapine may increase risk of SAb, ?PTLOther serotonergicsSSRIsTRAUMA + THE LABOR EXPERIENCEAvoiding exacerbations and preventing birth traumaEXAMPLES OF BIRTH TRAUMARISK FACTORSPerceptions of event, level of fear.Lack of control, felt overwhelmed.Emergency CS, assisted deliveries.Bleeding, pain, prolonged labor.Labor and delivery experienceLack of interpersonal support.No opportunities to process.Feelings of responsibility.Postpartum environmentTrauma history, especially sexual.Other psychiatric history.Individual vulnerability12 3TRAUMA-INFORMED CARE ON MATERNITY WARDWhat can we do as providers?Regardless of history of trauma:► Understand that trauma may be shared selectively► Listen to concerns► Explain what happens and why► Ask for consent and wait for a response► Reduce feelings of vulnerability► Offer what you can to limit stress, including:► Control over the situation► Medications► Environmental changes► Bystanders/SupportKnown history of trauma:► Do whatever you can to avoid inflicting further trauma► If you cannot accommodate, be apologetic and compassionate rather than dismissive and authoritarian► Discreetly share trauma history with triage, charge, and labor nurses► Make sure signout is updated with details other providers need to knowPOSTPARTUM CAREProcessing trauma ► Process the birth experience with all patients► Normalize experiences ► Avoid becoming defensive► Link to treatment when indicatedTRAUMA-INFORMED POSTPARTUM CAREWhat can we do as providers?PTSD MANAGEMENT + BREASTFEEDING• Cognitive Behavioral Therapy (CBT)• Eye Movement Desensitization and Reprocessing (EMDR)Psychotherapy• Generally safe• Paroxetine more likely to cause withdrawal, sedation• Don’t switch what is working • Limited data• Use shared decision-makingPrazosin• SNRIs appear to be safe, particularly venlafaxine• Mirtazapine not well studiedOther serotonergicsSSRIsTRAUMA INFORMED CAREA New Approach to Clinical PracticeRecognizes that trauma is pervasiveWe should assume that an individual is more likely than not to have a history of traumaWe should consider that behaviors and personality        traits we find difficult may be (mal)adaptive or protectiveWe should shift our paradigm from, “What is wrong with this person?” to “What has happened to this person?”Avoids re-traumatization Any situation (often unintentional) that literally or symbolically resembles an individual’s trauma, triggering difficult feelings and reactions associated with the original traumaHistorical, intergenerational, or cultural trauma may also be presentPromotes empowerment and healingTrauma affects an individual’s sense of self, their sense of others, and their beliefs about the world around themHaving a degree of control over uncertain situations becomes very importantTraumaInformedCareEXAMPLES OF TRAUMA INFORMED CAREThank youQuestions and comments welcomeWORKS CITED► Ayers, S. and Ford, E. (2012). PTSD following childbirth. In: Martin, C. R. (Ed.), Perinatal mental health: a clinical guide. (pp. 155-164). M&k Update. ISBN 1905539495 ► Birth Trauma Association (BTA). (n.d.). Retrieved from https://www.birthtraumaassociation.org.uk/► Burt, V. K., Suri, R., Altshuler, L., Stowe, Z., Hendrick, V. C., & Muntean, E. (2001). The Use of Psychotropic Medications During Breast-Feeding. American Journal of Psychiatry, 158(7), 1001-1009. doi:10.1176/appi.ajp.158.7.1001 ► Center for Substance Abuse Treatment (2014). Trauma-Informed Care in Behavioral Health Services. Rockville (MD): Substance Abuse and Mental Health Services Administration (US). (Treatment Improvement Protocol (TIP) Series, No. 57.) Exhibit 1.3-4, DSM-5 Diagnostic Criteria for PTSD.► Fisher, J., Astbury, J., & Smith, A. (1997). Adverse Psychological Impact of Operative Obstetric Interventions: A Prospective Longitudinal Study. Australian & New Zealand Journal of Psychiatry, 31(5), 728–738. doi: 10.3109/00048679709062687► Friedman, M. J. (n.d.). Trauma and Stress-Related Disorders in DSM-5. National Center for PTSD. https://istss.org/ISTSS_Main/media/Webinar_Recordings/RECFREE01/slides.pdf.► Howard-Young, J. M. (October , 2018). Personal notes from Women’s Health Panel Discussion at MGH Psychopharmacology Conference 2018. ► Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National Estimates of Exposure to Traumatic Events and PTSD Prevalence Using DSM-IV and DSM-5 Criteria. Journal of Traumatic Stress, 26(5), 537–547. doi: 10.1002/jts.21848WORKS CITED► Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National Estimates of Exposure to Traumatic Events and PTSD Prevalence Using DSM-IV and DSM-5 Criteria. Journal of Traumatic Stress, 26(5), 537–547. doi: 10.1002/jts.21848► Michelfelder, M., & Swoboda, E. (n.d.). (2012). Trauma 101. Trauma Informed Care Stakeholders Group Training Subcommittee. http://www.traumainformedcareproject.org/resources/Trauma 101 Powerpoint PresentationV1.pdf.► Morina, N., Wicherts, J. M., Lobbrecht, J., & Priebe, S. (2014). Remission from post-traumatic stress disorder in adults: A systematic review and meta-analysis of long term outcome studies. Clinical Psychology Review, 34(3), 249–255. doi: 10.1016/j.cpr.2014.03.002► Reed, R., Sharman, R., & Inglis, C. (2017). Women’s descriptions of childbirth trauma relating to care provider actions and interactions. BMC Pregnancy and Childbirth, 17(1). doi: 10.1186/s12884-016-1197-0► Robohm, J. S., & Buttenheim, M. (1997). The Gynecological Care Experience of Adult Survivors of Childhood Sexual Abuse: A Preliminary Investigation. Women & Health, 24(3), 59–75. doi: 10.1300/j013v24n03_04► Seng, J. S., Sperlich, M., & Low, L. K. (2008). Mental Health, Demographic, and Risk Behavior Profiles of Pregnant Survivors of Childhood and Adult Abuse. Journal of Midwifery & Womens Health, 53(6), 511–521. doi: 10.1016/j.jmwh.2008.04.013► Seng, J. S., Low, L. K., Sperlich, M., Ronis, D. L., & Liberzon, I. (2009). Prevalence, Trauma History, and Risk for Posttraumatic Stress Disorder Among Nulliparous Women in Maternity Care. Obstetrics & Gynecology, 114(4), 839–847. doi: 10.1097/aog.0b013e3181b8f8a2WORKS CITED► Suri, R., Lin, A. S., Cohen, L. S., & Altshuler, L. L. (2014). Acute and Long-Term Behavioral Outcome of Infants and Children Exposed in Utero to Either Maternal Depression or Antidepressants. The Journal of Clinical Psychiatry, 75(10). doi:10.4088/jcp.13r08926 ► Weissmen, A.M., Levy, B.T., Hartz, A.J., Bentler, S., Donohue, M., Elingrod, V.L., et al. (2004). Pooled analysis of antidepressant levels in lactating mothers, breast milk, and nursing infants. American Journal of Psychiatry, 161, 1066-1078. ► What is Trauma-Informed Care? (2019, February 25). Retrieved from http://socialwork.buffalo.edu/social-research/institutes-centers/institute-on-trauma-and-trauma-informed-care/what-is-trauma-informed-care.html► Yonkers, K. A., Smith, M. V., Forray, A., Epperson, C. N., Costello, D., Lin, H., & Belanger, K. (2014). Pregnant Women With Posttraumatic Stress Disorder and Risk of Preterm Birth. JAMA Psychiatry, 71(8), 897. doi: 10.1001/jamapsychiatry.2014.558

Trauma-Informed Peripartum Care

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Trauma-Informed Peripartum Care

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